Is the grass greener?
I have noticed that a number of the participants on this site are Canadians, which is only one reason I always keep my extra Canadian “u”s in my posts. There have been a few issues that have come up that might be different on the other side of the border, but for the most part, cancer is cancer and the questions are universal. However, a recent question on second line therapy prompted Dr West to wonder what happens in our more regulated health care system so I thought I’d provide a bit of a commentary. If you read my bio you will already know that I did all of my medical training in Canada but I did have the pleasure of spending a year in Nashville, Tennessee at the Vanderbilt-Ingram Cancer Center and University Medical Center. I spent this year in a lung cancer research fellowship that included at least 2 days a week in the clinics. So, although limited, I do feel that I have some sense of the similarities and differences in cancer care, at least in an academic setting.
Rather than get trapped in a debate about which country has a better system let’s just agree that there are good things and bad things about each one. Both could use some improving, neither is perfect, and both will need to evolve over time.
Access is usually the issue in Canada. We often seem to be “behind” the United States in terms of access to new drugs. Although we pay close attention to the rulings of the FDA, our own Health Canada carefully considers the evidence, data, and trials available for each new chemotherapy. And, even if a drug is approved for use in a given disease state, each province will have to decide if the drug will be paid for or not. If it is available then it is provided free, to everyone. If it is not covered by the province but it is approved by Health Canada, then patients can usually get access to it by paying for it themselves or sometimes through any additional health care insurance programs an individual patient might have. Additional health insurance is certainly not the norm, but it is relatively common. For example, pemetrexed (Alimta) is approved for use in the second line setting for advanced NSCLC, but most provinces do not pay for it (except in mesothelioma). It is paid for/covered in British Columbia, which is why I use it more than docetaxel (Taxotere) (mainly because of the hair loss issue), but I had no problem using the equally effective docetaxel before and I do not think that the other provinces are providing inferior treatment because they do not have it available.
There is a similar issue with erlotinib (Tarceva), which is covered by almost every province (and being reviewed by the territories) for use in second line if someone cannot take a taxane and for third-line treatment for any NSCLC. This approval is based on the trial (BR21) that demonstrated benefit in this particular group of people. It is not approved in first-line because the results for the studies that are testing that haven’t been released yet. I agree, it is tempting to give it a try first-line – why not? If it works later why shouldn’t it work first, right? Well, I’m not so sure, and I think looking before you leap might be wise sometimes.
For example, erlotinib works by itself, we saw that from the phase II studies in the 1990s. Chemotherapy agents seem to work best when we combine them together – carbo/taxol or gem/cis so it must be that all 3 together would work even better. Right? Except when this concept was tested on over 4000 people there was no benefit to adding in the erlotinib (or gefitinib). Good thing we tested it rather than just adding it in automatically.
That’s not to say I haven’t used erlotinib first line. In fact I have a clinical trial open right now that is testing this exactly, with a solid rationale and a thorough ethics review. Beyond trials, I must admit it makes me nervous, though in individual cases I think it is worth considering.
Yes, I admit that it is sometimes incredibly frustrating that I cannot have access to every new drug that comes up in any creative combination for as long as I want to use it for. But this is supposed to be an evidence-based practice; the people I’m treating deserve a rationale for what I prescribe. And I believe that as responsible physicians we do need to put some thought into the cost of what we’re recommending. There is not an endless health care budget, in Canada but also in the USA. Even at a patient level, is it worth spending the last few months of your life struggling to go to work so you won’t lose the insurance that pays for your $200,000 of chemotherapy that maybe only adds 2 weeks to your survival?
Someone will ask about Canadian waitlists – yes, this can be a problem. Sometimes it takes 2 weeks to get a CT scan or 2 weeks to book an appointment for palliative chemotherapy. That waiting can be very anxiety-provoking for patients and families. From a biological point of view, it’s hard to know how much difference a week or two makes. When it does make a difference, in a curative situation or in a medical emergency, there is no waiting.
So of course there are differences. Having worked in both countries, I see that there are a lot of misconceptions about the other’s systems and there is a huge amount of variability for individual situations. Hopefully we can learn from each other.
posted by Dr Laskin @ 11:13 pm link to this post
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January 31st, 2008 at 6:45 am
Hi Dr. Laskin,
As a US citizen who lived in Canada for a few years, and who was diagnosed with and treated for lung cancer there, I just have to add my perspective.
My experience was that access to care and waitlists were a much bigger problem than you describe. I was in Montreal, so I can only speak for how things are done in Quebec (which is probably different from the other provinces as is usually the case with Quebec).
Getting appointments in a timely way was a constant, galling problem. I often had the experience of finally getting in to see someone, only to have my next appointment cancelled with no explanation, or to have the doctor disappear on another rotation for a month or more. Once I was diagnosed, scheduling CT scans was not difficult, but the pre-diagnosis waitlists for tests were breathtaking–months and months long. I fortunately had additional insurance and was able to bypass many of these waits by going to private clinics, but as you pointed out, this is not the norm in Canada and most people just have to wait, or pay out of their own funds. I can’t see how this wouldn’t negatively affect outcomes.
There are simply not enough doctors to meet the needs of the residents of Quebec, and I know by reading the papers that most of the other provinces have the same problem. I don’t completely understand why. Is the health care system underfunded? Is it being run badly? Are people discouraged from going into or staying in the medical profession by governmental bureaucracy?
Still, I think in general there is a lot to be said for the Canadian system, just as there is a lot of good in the US system. Also, I find that people tend to exaggerate the negatives of the system that they are NOT in, and to minimize the very serious problems in their own country. Perhaps a “blended” system of single-payer and private insurance is the answer. I have heard a lot of discussion about Canada heading that direction, and that is encouraging. I don’t think the talk in the US about bringing in an single-payer system (beyond Medicaid/Medicare & the VA) is really going anywhere right now. That is unfortunate.
Just a little postscript: I now live back in the US. I returned here with my family a few months ago because our application for Permanent Residence in Canada would not go through because of my cancer diagnosis. I was found to medically ineligible–in other words, expensive. And, I WAS on Tarceva first-line while there and it was NOT covered. My private insurance covered half of the $2800/month cost. Here in the US, my spouse’s employer’s insurance will cover it, at $6 a month. It’s all great–as long as we have insurance. If not, Tarceva here is nearly $4000 per month. So, there you have it.
Leslie
January 31st, 2008 at 5:46 pm
Dr. Laskin,
Thank you for the piece on cancer care in the Canadian system. As a resident of Ontario. I’m interested in learning about differences between Canada and the U.S.
For those who might be interested in experiences from a Canadian perspective, I can add the following
My husband was diagnosed with NSCLC in early December after being admitted through the ER of a major hospital with an associated cancer center. He was kept in the hospital for 10 days to treat a very serious secondary lung infection which occurred due a tumor blocking an airway. During this time, all of his tests were taken care of and his cancer staged, etc.. Unfortunately, previous to being admitted to the ER, there was quite a bit of time wasted while he visited his GP several times over about 3 months with complaints of breathing difficulties (he was treated as though he had asthma or allergies). I should add that, after reading numerous case histories posted by members on a couple of lung cancer survivor forums, I’ve noticed that many people seem to have had the same experience as my husband (misdiagnosis and treatment as asthma). It kind of makes me want to print up some info on recognizing lung cancer and sendin it around to GP’s offices!). Anyhow, I regard the wasted time with the GP to have been less a case of how the Canadian system works, and more a case of an individual doctor’s ineptness (I’m afraid that’s about as kind an adjective as I can come up with). As far as treatment has been concerned, that had to be delayed for several weeks due to the infection (it was very serious and took awhile to clear up). However, once we got that out of the way, I believe that things have moved along fairly well as far as getting going with first line treatment. I don’t know much about which treatments will be easily available here in Ontario if we get to second line or beyond, but I guess we’ll learn more about this depending on how things go.
January 31st, 2008 at 10:01 pm
I wonder if I am the only one from Australia coming to this site?
It is interesting to read about the different health systems.
My husband has BAC and is about to start chemo… Carboplatin and Gemcitabine. I asked the Onc about Alimta as it has just been approved here in Australia..Seems you can only get it if you have mesotheioma.
With regards diognosis. My husband was treated for allergies then pnumonia We were even told our cats might be the problem….. Then sent to a Thoracic Spec. He spent 2 months trying this and that…. Testing this and that and a brochoscopy. He actually asked me if I had any ideas.!!
Over three months wasted. Mark ended up having nearly all his right lung removed. Choking with Mucinous B A C
Sylvia
January 31st, 2008 at 11:08 pm
Thanks to all of you for your perspectives. Dr Laskin may well want to add some of her own comments in response.
I would just add that it’s quite typical for patients to at go at least 2-4 weeks, and not unusually 1-2 months, being seen and treated for a pneumonia, asthma, allergies, etc. before the diagnosis of lung cancer is made. If I had to generate a “classic” history of someone with newly diagnosed lung cancer it would be an abnormal chest x-ray finding along with cough (or some variant lung-based symptom) that does not improve after a course or two of antibiotics. And if someone were to ask me what form of lung cancer would be most likely to be mistaken for pneumonia based on imaging appearance (and probably symptoms as well), I would answer BAC. I’m sorry, Sylvia, about Mark’s delayed diagnosis, but as someone who sees lots of BAC cases, it’s especially common for such cases to treated as an infection for a long time before the BAC diagnosis is ultimately made.
-Dr. West
February 1st, 2008 at 8:00 pm
Thank you for sharing your stories. i’d have to agree with Dr West that very often lung cancers are “eventually” diagnosed in the follow-up time after having a lung infection treated. And of course everything becomes more clear in retrospect and also, doctors sometimes miss things that they shouldn’t.
Overall, I think this is the same issue as frequent CT scans, often they show things that aren’t cancer or are questionable and need to be followed. most of the time these things are not cancer, but of course we all remember the cases when it does turn out to be cancer.
the other thing to note is that changes on scans, CT or x-rays, that are due to infections often last for several months even after the clinical signs of the infection are gone. so usually repeating these scans 8 - 12 weeks after the infection is the most practical thing to do, if it is repeated too early it will look the same as if an active infection is still present and may not show a cacner at all.
clearly we need to find a better way to detect lung cancers earlier. but of course this is not purely a Canadian problem!